P-wave peak time: An emerging electrocardiographic marker of atrial stress and ischemic burden-review

The 12‑lead electrocardiogram (ECG) remains a cornerstone of cardiovascular assessment, providing a noninvasive window into cardiac electrical and structural function beyond other markers of ischemia and arrhythmias. P-wave peak time (PWPT), defined as the interval from P-wave onset to its maximal amplitude, has emerged as a novel electrocardiographic marker of atrial conduction and hemodynamic stress. Increasing evidence suggests that PWPT prolongation accompanies elevated ventricular filling pressures, atrial stretch, and chronic atrial remodeling across a spectrum of ischemic conditions, including both obstructive coronary artery disease and ischemia with no obstructive coronary arteries (INOCA). In addition to serving as a marker of acute ischemia, PWPT also appears to capture long-term atrial structural and electrophysiologic changes, including fibrosis and conduction slowing. These same processes are central to the development of atrial fibrillation, providing a biologically plausible link between PWPT prolongation and arrhythmogenic risk. Moreover, given its simplicity and compatibility with computerized ECG analysis, PWPT represents a promising adjunctive marker for cardiovascular risk stratification. Further investigation in larger and more diverse populations is warranted to define its prognostic significance and clinical utility.